Healthcare is in a state of crisis across the nation. This, coupled with the impending nursing shortage and regulatory pressures, creates tension as well as an overall awareness for the need for change. Oncology patients admitted to Contra Costa Regional Medical Center (CCRMC) for chemotherapy treatments, as in many hospitals across the country, are sent to the medical/surgical unit. The caseload of patients receiving chemotherapy can vary week to week and month to month. As a result, maintaining competency and safe practice are challenging for the nursing staff.
Located in northern California and serving a population of 1 million residents, Contra Costa Health Services consists of an integrated health delivery system and was the first federally qualified, publicly sponsored health plan in the country. As the safety net for the county, CCRMC is a 166-bed acutecare facility with the mission to provide healthcare for all people, paying special attention to those who are most vulnerable to health problems. This health system provides the physical facilities and system structures that reach into a medically underserved community and provides services to those who otherwise may be without care. The outpatient cancer center and infusion clinic handles the vast majority of cancer patients and their chemotherapy administrations. However, initial conditions leading to diagnosis, surgical recovery, long-term infusions, and treatment of side effects may occur in the inpatient setting. In addition, some patients may require hospitalization for treatment because of a nonexistent or unstable home environment or a lack of support services (eg, home health nurse visits or a significant other to assist in the home). The need In the late 1980s, CCRMC nurses interested in chemotherapy administration were encouraged to attend a chemotherapy course developed by one author and were mentored in safe administration practice. In the 1990s, the Oncology Nursing Society (ONS) Chemotherapy and Biotherapy course became the standard coursework, and its clinical practicum evaluation tool became the standard competency checklist for registered nurses new to chemotherapy administration. In the late 1990s, it became a requirement for CCRMC nurses to have a current ONS chemotherapy and biotherapy provider card, attend an oncology-related continuing education course annually, and administer a minimum of three chemo therapy infusions annually to maintain competency. Many registered nurses volunteered to go through this process to become approved by CCRMC to administer chemotherapy. Over the next decade, most chemo therapy administration gradually shifted from the inpatient to the outpatient setting. As a consequence, inpatient staff nurses had inconsistent opportunities to administer chemo therapy, and maintaining competency in a low-volume, high-risk procedure became a challenge. However, some oncology patients continued to be admitted to the hospital for chemotherapy treatment or for other reasons, such as treatment-related side effects and cancer-related complications. Many staff members felt ill-prepared to handle the assessment and management of oncology patients' needs. The emotional impact of working with patients coping with cancer cannot be underestimated for staff members unfamiliar with expected and unexpected presentations, treatment needs, and psychosocial issues. Staff members unprepared for the emotional toll became stressed as a result of concern about not being prepared to adequately handle their patients' needs in a safe, timely, and supportive fashion. Eventually, many staff nurses felt the need to refuse to administer chemotherapy, as they no longer felt competent. This made staffing to accommodate 24-hour infusion support for oncology patients a challenge. Fulfilling the need Since 2007, all registered nurses on the CCRMC medical unit are required to maintain a current ONS chemotherapy and biotherapy provider card. New hires to the unit are required to successfully attend the ONS course and pass the posttest within 6 months of hire. The ONS Chemotherapy and Biotherapy Guidelines and Recommendations for Practice has specific recommendations for nursing education and demonstration of competency.1 Completion of an acceptable didactic component and clinical practicum has be come standardized nationally through the ONS course. CCRMC has provided the ONS 2-day course for its staff and the community for several years to ensure consistency and quality of education. On successful completion of the course and posttest, participants receive an ONS chemo therapy and biotherapy provider card. This card is renewable every 2 years by successfully completing an online renewal course that covers updates related to oncology nursing clinical practice. Each month, an oncology clinical nurse specialist teaches the ONS chemotherapy and biotherapy course, which allows all the medical unit nurses to take the course without adversely affecting staffing levels. Nurses who want to become competent in chemotherapy administration are proctored through a minimum of three successful chemotherapy administrations, including calculation of dosages, evaluation of laboratory data, patient and family education, venipuncture/central-line access, safe and proficient handling/administration/disposal, and documentation. These nurses are given the option of being proctored on the unit by an experienced CCRMC chemotherapy-approved nurse, or spending a day in the cancer center infusion clinic and working directly with the outpatient oncology nurses. Nurses proctored on the medical unit are assigned a light patient load to allow them time to focus on the chemotherapy. Nurses rotating through the infusion clinic tend to express a greater satisfaction with the training because they are able to focus on chemotherapy administration safety processes without having a patient load. As a result of this training program, each shift has developed a core group of nurses who administer chemotherapy, as well as serve as resources to other staff members on the medical unit and in other departments in the hospital. In addition, the other medical unit staff nurses have better preparation to proactively prevent and/or treat oncology-related side effects and handle discharge considerations. As a group, the staff has developed prep rinted chemotherapy orders specific to inpatient processes. Inpatient oncology staff meetings address patient care concerns. In ad dition, the staff nurses have e nhanced teamwork and communication with the pharmacy and outpatient oncology staff, streamlining patient care. Conclusion Safe and competent administration of chemotherapy and biotherapy in the inpatient setting of small hospitals can be challenging and stressful for staff nurses. Competency can be developed through standardized education and mentoring, with required updates to ensure continued competency. By providing the ONS chemotherapy and biotherapy course, CCRMC has developed a medical unit team with a baseline knowledge of chemotherapy treatment and side effects, who feel better prepared to handle the special needs of oncology patients. Reference
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